Selective Right Atrial Thrombectomy for Clot-in-Transit With Dynamic Tricuspid Inflow Obstruction Complicating Acute Pulmonary Embolism.

IMAGE(S): Computed tomography and transthoracic echocardiography demonstrating right atrial (RA) clot-in-transit (CIT) causing dynamic tricuspid inflow obstruction in acute pulmonary embolism.

CASE SUMMARY: A 96-year-old woman presented with recurrent syncope, hypoxia, and shock requiring vasopressor support. Imaging demonstrated acute pulmonary embolism with right ventricular dilation/dysfunction and a mobile RA CIT intermittently prolapsing across the tricuspid valve. Systemic thrombolysis was contraindicated because of recent ischemic stroke. Selective RA aspiration thrombectomy removed a 15-cm thrombus, resulting in immediate hemodynamic improvement.

TAKE-HOME MESSAGES: Dynamic tricuspid inflow obstruction may contribute to shock in CIT complicating acute pulmonary embolism. Selective intracardiac thrombectomy may rapidly restore hemodynamic stability.